Fremont Village

87608(a) ...the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.This requirement is not met as evidenced by: Based on observations and interview, the licensee did not comply with the section cited above by having a seatbelt as postural support for residents in wheelchairs without an exception request which poses a potential safety risk to persons in care.

87303(c) All window screens shall be clean and maintained in good repair.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having window blinds in disrepair in multiple residents’ room which poses a potential safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above by having items including but not limited to hydrocortisone cream, Ketoconazole 2% shampoo, prescribed cerave face wash, saline wound cleanser, One Day Vitamin, insulin, etc., in residents' room unlocked and accessible to residents' in care which poses an immediate safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not having an updated Appraisal Needs and Services Plan (LIC625) for R1, R2, R4, and R7 which poses a potential health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above by having items in disrepair such as dresser handle, ac in the memory care unit, air conditioning in the dining hall, dirty showers, resident’s toilet covered in feces, dirty showers. LPAs also observed items such as foul odor, washing machine, portable heaters, broken toilet, old mattress left out which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above by not having the hot water temperature measured within range which poses a potential safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above by having a resident's family member reside in the resident's room which poses a potential personal rights risk to persons in care.

Based on observations, the licensee did not comply with the section cited above by having items including but not limited to disinfectant spray, acetone nail polish remover, Arm & Hammer Odor Blaster, laundry detergent, Lysol spray, etc., in multiple areas at the facility unlocked and accessible to residents' in care which poses an immediate safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above by multiple boxes of sugar dated 05/01/2019 and expired in 2021, canned goods and opened pasta not properly labeled. LPAs also observed mineral oil in a Purell Surface Disinfectant Spray bottle which poses a potential health and safety risk to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above by medications prepoured to be administered the following day which poses a potential health and safety risk to persons in care.

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services...This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having auditory signal device displaced, R1's windowsill broken, and rust on the closet panel.

87705(d) Care of Persons with Dementia(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates...This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above by not having the auditory signal on at the time R1 AWOL from the facility which posed a potential safety risk to residents in care.

Based on record review, the licensee did not comply with the section cited above in having S6 not associated to the facility which poses an immediate health and safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not having an updated Appraisals Needs and Services Plan for R1 to R6 which poses a potential health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in having a malfunction thermostat in the freezer which poses a potential health and safety risk to persons in care.

87465(g) Incidental Medical and Dental Care(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).This requirement is not met as evidenced by: Based on interviews and record reviews conducted, 1) S2 failed to perform CPR for R1 immediately 2) the facility failed to call 911 immediately for R1. R1 was found unresponsive at 5am, 911 call was placed at 5:21 am.

Maintenance and Operation.The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by having inoperable heater which poses a potential health and safety risk to the persons in care.

Based on observation the licensee did not comply with the section cited above. LPA observed two cartons of Lactaid in the refrigerator that expired August 10, 2021 which poses a potential health, safety or personal rights risk to persons in care.

87506 Resident Records (a) The licensee shall ensure that a... current record is maintained for each resident in the facility... to licensing agency staff. The requirement was not met as evidence by: Based on LPA's record review licensee did not comply with the section cited above which poses a potential health and safety risk to persons in care.

87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe... accommodations .. This requirement was not met as evidence by: Based on LPA's interviews licensee did not comply with the section cited above which poses an immediate health and safety risk to persons in care.